Provider Demographics
NPI:1114717527
Name:GNAGNARELLI, TARA JEANINE (LMT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:JEANINE
Last Name:GNAGNARELLI
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 OAKDALE MNR APT C2
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-5722
Mailing Address - Country:US
Mailing Address - Phone:845-709-9528
Mailing Address - Fax:
Practice Address - Street 1:1 DEWOLF RD STE 208
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675-7084
Practice Address - Country:US
Practice Address - Phone:201-497-6612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01498600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist